<form id="add-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">
	<div class="form-group">
		<label class="control-label col-xs-12 col-sm-2">{:__('Name')}:</label>
		<div class="col-xs-12 col-sm-8">
			<input id="c-name" data-rule="required" class="form-control" name="row[name]" type="text" />
		</div>
	</div>
	<div class="form-group">
		<label class="control-label col-xs-12 col-sm-2">{:__('Mobile')}:</label>
		<div class="col-xs-12 col-sm-8">
			<input id="c-name" data-rule="required" class="form-control" name="row[mobile]" type="text" />
		</div>
	</div>
	<div class="form-group">
		<label class="control-label col-xs-12 col-sm-2">{:__('Region')}:</label>
		<div class="col-xs-12 col-sm-8">
			<div class="control-relative">
				<input id="c-Region" data-rule="required" class="form-control" data-toggle="city-picker" type="text" />
				<input type="hidden" data-rule="required" name="row[code]" id="code" />
			</div>
		</div>
	</div>
	<div class="form-group">
		<label class="control-label col-xs-12 col-sm-2">{:__('Address')}:</label>
		<div class="col-xs-12 col-sm-8">
			<input id="c-name" data-rule="required" class="form-control" name="row[address]" type="text" />
		</div>
	</div>

	<div class="form-group layer-footer">
		<label class="control-label col-xs-12 col-sm-2"></label>
		<div class="col-xs-12 col-sm-8">
			<button type="submit" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
			<button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
		</div>
	</div>
</form>
